NCLEX-RN
NCLEX RN Exam Questions
1. Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent's remark: "We just don't know how he caught the disease!"? The nurse's response is based on an understanding that:
- A. AGN is a streptococcal infection that involves the kidney tubules.
- B. The disease is easily transmissible in schools and camps.
- C. The illness is usually associated with chronic respiratory infections.
- D. It is not "caught"? but is a response to a previous B-hemolytic strep infection.
Correct answer: D
Rationale: The correct answer is that acute glomerulonephritis (AGN) is not 'caught' but is a response to a previous B-hemolytic strep infection. AGN is generally accepted as an immune-complex disease triggered by an antecedent streptococcal infection occurring 4 to 6 weeks prior. It is considered a noninfectious renal disease. Choice A is incorrect because AGN is not a streptococcal infection that involves the kidney tubules but rather a noninfectious renal disease. Choice B is incorrect as AGN is not easily transmissible in schools and camps but is a result of a previous streptococcal infection. Choice C is incorrect as AGN is not usually associated with chronic respiratory infections, but with a previous streptococcal infection.
2. What nursing action demonstrates the nurse understands the priority nursing diagnosis when caring for patients being treated with splints, casts, or traction?
- A. The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour.
- B. The nurse orders meals with adequate protein and calcium for the patient.
- C. The nurse teaches the patient never to insert objects under a cast to scratch an itch.
- D. The nurse administers oral painkillers as ordered.
Correct answer: A
Rationale: The correct answer is to assess extremity pulse, temperature, color, pain, and feeling every hour. This action aligns with the priority nursing diagnosis of Risk for Peripheral Neurovascular Dysfunction related to fractures. Monitoring these factors is crucial to detect any signs of compromised circulation or nerve function promptly. Option B is incorrect as it does not directly address the priority nursing diagnosis. Option C is important but does not directly relate to the neurovascular aspect. Option D, administering painkillers, is necessary but does not specifically address the priority nursing diagnosis of neurovascular dysfunction.
3. After assessing Mr. B, what is the initial action of the nurse?
- A. Immediately place the client in a negative-pressure room
- B. Set the client up to receive a bronchoscopy
- C. Contact the physician for antifungal medications
- D. Administer oxygen and assist the client to sit in the semi-Fowler's position
Correct answer: A
Rationale: The first action the nurse should take after assessing Mr. B is to administer oxygen and assist him to sit in the semi-Fowler's position. Administering oxygen helps improve tissue oxygenation, while sitting up in a semi-Fowler's position aids in better breathing and secretion clearance. Placing the client in a negative-pressure room is not the immediate priority unless isolation is needed. Performing a bronchoscopy or contacting the physician for antifungal medications is not the initial step in managing a client with suspected pneumonia.
4. A patient asks a nurse, "My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acid?'
- A. Green vegetables and liver
- B. Yellow vegetables and red meat
- C. Carrots
- D. Milk
Correct answer: A
Rationale: Green vegetables and liver are rich sources of folic acid. Green vegetables like spinach, asparagus, and broccoli are high in folic acid content. Liver, especially from chicken or beef, is also a good source of folic acid. Yellow vegetables and red meat (choice B) do not contain as high a concentration of folic acid as green vegetables and liver. Carrots (choice C) are nutritious but do not have the highest concentration of folic acid. Milk (choice D) is not a significant source of folic acid compared to green vegetables and liver.
5. When asked to describe in layman's terms an overview of the condition called osteomyelitis, what would be the nurse's best response?
- A. Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age-related.
- B. Osteomyelitis is caused by not having enough Vitamin D, which in turn causes your bones to be softer and demineralized.
- C. Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body.
- D. This is a question that should be directed to your healthcare provider.
Correct answer: C
Rationale: Osteomyelitis is an infection in the bone that can be caused by bacteria reaching the bone either from outside the body (such as through an open fracture) or inside the body (such as through the bloodstream). This response provides a concise and accurate explanation of osteomyelitis, making it the best choice. Choices A and B provide inaccurate information about the condition, attributing it to age-related bone breakdown and Vitamin D deficiency, which are not correct causes of osteomyelitis. Choice D deflects the question instead of providing the patient with a clear explanation, making it an inappropriate response.
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